A report has highlighted failings in the care of a traumatised rape victim in the run-up to his untimely death.

The man, referred to as ‘James’ in a safeguarding report, was just 34 when he was found dead at his sister’s home. His family believed he would not have declined so much before his death from alcoholic ketoacidosis if support had been in place sooner.

Following James’ death, a Learning from Life and Death Review was carried out.

However, there remained concerns regarding the way agencies had worked together in James’ case and a Safeguarding Adults Review was carried out by Teeswide Safeguarding Adults Board.

The review covered the 11 months until James died in 2021 when his risk was escalating and concerns were being raised. It noted that James’ family and carer were clear that they wanted professionals to learn from his death.

James had the support of an informal carer, without whom he would neglect his hygiene, the report stated. It said James required a greater deal of support than was realised by professionals, his mental capacity to not engage was not assessed effectively and a safeguarding referral in respect of his self-neglect was not made.

Who was James and what happened in his care?

James was born deaf and, from the age of just five, spent his childhood in various foster homes and children’s homes. He was raped at the aged of 12.

“Later James was known to be offering sexual favours for cash and was being sexually exploited by an adult male,” said the report. “This sexualised behaviour then continued into his adult life with concerns regarding him sex working.”

James displayed symptoms of trauma throughout his life and used drugs and alcohol as a result. He also had diabetes, ADHD and dyslexia and was diagnosed as having a borderline learning disability when he was an adult.

The family and his carer said James was known by many people in the area where he lived and he was ‘very gullible’. This often led to problems for him but that he was always thinking and caring for others, they said.

He was supported by adult social care services from just two years and five months before he died. He was referred to an intensive support team, who provided him with a key worker until about a year before his death.

Referrals were made by the local authority to the mental health trust. Ultimately James was discharged from the trust’s service due to the team not being able to engage with him, said the report.

The alcohol support service also stepped in but James was eventually discharged, again for failing to engage. “It was not always clear how much of his non-engagement was due to lack of understanding how and why he could access services for support,” said the report.

“It does not appear that the safeguarding system was used as effectively as it might have been and there is evidence that each organisation, albeit referring to other services when appropriate, did not appear to work effectively together as a support network around James. As a vulnerable dependant drinker, James needed a multi-agency response rather than each agency providing a single agency response, albeit there was recognised single agency good practice.”

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A further referral was made by a social worker four months later and assessment and support were offered but this did not pan out before James died. The report also said comments from family members and professionals highlighted that, in order to be able to address his own needs successfully, James needed a team around him who were able to work in a trauma-informed way.

The report said: “James was clear in his voice when he stated that he got fed up with telling his story over and over again and indicated that it retraumatised him. James appeared to therefore have insight into the impact of his trauma, but professionals did not appear to have been able to prevent him from telling his story repeatedly.

“This is a complex issue as, in order to understand a person, we need to understand their story but, where this leads to constant revisiting and therefore retraumatising, that is not in line with trauma-informed practice. Police have identified that on occasion it would have been better to have used out of court responses to some of the criminal activity that James was involved in (mostly when intoxicated) in recognition of a more trauma-informed response. ”

What were some of the recommendations in the report?

It was recommended that the safeguarding board should strengthen work to promote multi-disciplinary meetings being used.

A key worker must be named who is the professional that is acceptable to the person and knows the person best

A ‘learning briefing’ should be produced regarding the role of informal carers and the importance of understanding the role and offering carers assessments.

Practitioners should be advised that the offer of a ‘carers assessment’ should not be a ‘tick box’ exercise and should be undertaken in a sensitive and needs-led approach.

Where assessment or referral identifies a person with low levels of literacy, letters and appointments should be sent using ‘Easy Read’ versions.

What has already changed?

The mental health trust now has an assertive outreach team that is able to offer a more trauma-informed approach. There are developments to provide a specialist substance misuse social worker within adult social care.

The safeguarding board has produced two new documents to continue to try and support practitioners in the area of mental capacity assessment.

What has the TSAB said in response to the report?

Darren Best, Independent Chair of the Teeswide Safeguarding Adults Board, said: “Our thoughts are with James’s family and friends during this difficult time. The review has highlighted some of the limitations of protecting an adult like James, however during the review I have seen how determined multiple agencies are to improve and make the necessary changes.

“As the Independent Chair of the TSAB I will work with the relevant organisations to ensure we provide better outcomes for the people we support in our communities.”